Third-Party Providers

Third-Party Care Provider Relationships

Many Affordable Dentures & Implants affiliated practices have established community partnerships or third-party care provider relationships with government and social service organizations, nursing home and retirement home facilities, hospices, hospitals, churches and home health agencies. Organizations like the U.S. Department of Veterans Affairs often use the dental services offered by our affiliated practices to supplement the services provided within the VA medical system.

Working With us as a Third-Party Care Provider

Our practices generally require payment at the time of service. However, if you have clients, patients or residents for whom your organization will be making payment, we will be glad to establish an agreement in which the practice will accept organization checks or bill the organization for the services that are provided. We can also provide organizations with an approved W-9 Request for Taxpayer Identification Number and Certification IRS form if it assists your organization in the processing of a qualified patient's payment for services.

To set up a third-party care provider agreement, please submit the following web form. A representative will respond to your request within 48 business hours.

fullName:

emailAddress:

Organization Information

Tax ID:

Name of Organization:

Billing Address:

City:

State/Province:

Zip/Postal Code:

Contact Person:

E-Mail:

Telephone:

Ext.:

Fax:

Check only one

Bill my organization
Payment will be sent with patient

This form will be valid from:

This form will be valid until:

Patient Information

Patient's First Name:

Patient's Last Name:

Patient Phone:

Affordable Dentures Office to Visit:

Amount Not to Exceed:

Service(s) Patient needs:

Notes:

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Thank You

Thank you for contacting us. A member of the Third Party Providers team will review your submission and follow up with you.

For any questions or concerns about this process please email thirdpartypay@affordablecare.com.